Lifting the curtain on the emergency department crisis: a multi-method reception study of Larry Saves the Canadian Healthcare System.

BACKGROUND: Despite growing evidence of the potential of arts-based modalities to translate knowledge and spark discussion on complex issues, applications to health policy are rare. This study explored the potential of a research-based theatrical video to increase public capacity and motivation to engage with the complex issues that make Emergency Department wait times such an intractable problem. METHODS: Larry Saves the Canadian Healthcare System is a digital musical micro-series developed from extensive research examining system-level causes of Emergency crowding and the ineffectiveness of prevailing approaches. We released individual episodes and a revised full-length version on YouTube, using organic promotion strategies and paid advertising. We used YouTube Analytics to track views, engagement and viewer demographics, and content-analyzed viewer comments. We also conducted five university-based screenings; 92 students completed questionnaires, rating Larry on 16 descriptors using a 7-point Likert scale. RESULTS: From June 2022 through May 2023, Larry garnered over 100,000 views (76,752 of the full-length version, 35,535 of episodes), 1329 likes, 2780 shares, and 139 comments. Views and watch time were higher among women and positively associated with age. Among YouTube comments, the predominating themes were praise for the video and criticism of the healthcare system. Many commenters applauded the show's accuracy, humor, and/or resonance with their experience; several shared healthcare horror stories. Students overwhelmingly agreed with all positive and disagreed with all negative descriptors, and nearly unanimously deemed the video informative, thought-provoking, and entertaining. Most also affirmed that it had increased their knowledge, interest, and confidence to participate in discussions about healthcare issues. Neither gender, primary language, nor employment in healthcare predicted ratings, but graduate students and those 25+ years old evaluated the video most positively. DISCUSSION: These findings highlight the promise of research-informed musical satire to inform and invigorate discourse on an urgent health policy problem. Larry has reached tens of thousands of viewers, garnered excellent feedback, and received high student ratings. Further research should directly assess educational and behavioural outcomes and explore what facilitative strategies could maximize this knowledge translation product's potential to foster informed, impactful policy dialogue.

Developing a set of emergency department performance measures to evaluate delirium care quality for older adults: a modified e-Delphi study.

BACKGROUND: Older adults are at high risk of developing delirium in the emergency department (ED); however, it is under-recognized in routine clinical care. Lack of detection and treatment is associated with poor outcomes, such as mortality. Performance measures (PMs) are needed to identify variations in quality care to help guide improvement strategies. The purpose of this study is to gain consensus on a set of quality statements and PMs that can be used to evaluate delirium care quality for older ED patients. METHODS: A 3-round modified e-Delphi study was conducted with ED clinical experts. In each round, participants rated quality statements according to the concepts of importance and actionability, then their associated PMs according to the concept of necessity (1-9 Likert scales), with the ability to comment on each. Consensus and stability were evaluated using a priori criteria using descriptive statistics. Qualitative data was examined to identify themes within and across quality statements and PMs, which went through a participant validation exercise in the final round. RESULTS: Twenty-two experts participated, 95.5% were from west or central Canada. From 10 quality statements and 24 PMs, consensus was achieved for six quality statements and 22 PMs. Qualitative data supported justification for including three quality statements and one PM that achieved consensus slightly below a priori criteria. Three overarching themes emerged from the qualitative data related to quality statement actionability. Nine quality statements, nine structure PMs, and 14 process PMs are included in the final set, addressing four areas of delirium care: screening, diagnosis, risk reduction and management. CONCLUSION: Results provide a set of quality statements and PMs that are important, actionable, and necessary to a diverse group of clinical experts. To our knowledge, this is the first known study to develop a de novo set of guideline-based quality statements and PMs to evaluate the quality of delirium care older adults receive in the ED setting.

Evaluating the quality of research co-production: Research Quality Plus for Co-Production (RQ + 4 Co-Pro).

BACKGROUND: Co-production is an umbrella term used to describe the process of generating knowledge through partnerships between researchers and those who will use or benefit from research. Multiple advantages of research co-production have been hypothesized, and in some cases documented, in both the academic and practice record. However, there are significant gaps in understanding how to evaluate the quality of co-production. This gap in rigorous evaluation undermines the potential of both co-production and co-producers. METHODS: This research tests the relevance and utility of a novel evaluation framework: Research Quality Plus for Co-Production (RQ + 4 Co-Pro). Following a co-production approach ourselves, our team collaborated to develop study objectives, questions, analysis, and results sharing strategies. We used a dyadic field-test design to execute RQ + 4 Co-Pro evaluations amongst 18 independently recruited subject matter experts. We used standardized reporting templates and qualitative interviews to collect data from field-test participants, and thematic assessment and deliberative dialogue for analysis. Main limitations include that field-test participation included only health research projects and health researchers and this will limit perspective included in the study, and, that our own co-production team does not include all potential perspectives that may add value to this work. RESULTS: The field test surfaced strong support for the relevance and utility of RQ + 4 Co-Pro as an evaluation approach and framework. Research participants shared opportunities for fine-tuning language and criteria within the prototype version, but also, for alternative uses and users of RQ + 4 Co-Pro. All research participants suggested RQ + 4 Co-Pro offered an opportunity for improving how co-production is evaluated and advanced. This facilitated our revision and publication herein of a field-tested RQ + 4 Co-Pro Framework and Assessment Instrument. CONCLUSION: Evaluation is necessary for understanding and improving co-production, and, for ensuring co-production delivers on its promise of better health.. RQ + 4 Co-Pro provides a practical evaluation approach and framework that we invite co-producers and stewards of co-production-including the funders, publishers, and universities who increasingly encourage socially relevant research-to study, adapt, and apply.

Managing intergroup silos to improve patient flow.

BACKGROUND: Health care managers face the critical challenge of overcoming divisions among the many groups involved in patient care, a problem intensified when patients must flow across multiple settings. Surprisingly, however, the patient flow literature rarely engages with its intergroup dimension. PURPOSE: This study explored how managers with responsibility for patient flow understand and approach intergroup divisions and "silo-ing" in health care. METHODOLOGY/APPROACH: We conducted in-depth interviews with 300 purposively sampled senior, middle, and frontline managers across 10 Canadian health jurisdictions. We undertook thematic analysis using sensitizing concepts drawn from the social identity approach. RESULTS: Silos, at multiple levels, were reported in every jurisdiction. The main strategies for ameliorating silos were provision of formal opportunities for staff collaboration, persuasive messages stressing shared values or responsibilities, and structural reorganization to redraw group boundaries. Participants emphasized the benefits of the first two but described structural change as neither necessary nor sufficient for improved collaboration. CONCLUSION: Silos, though an unavoidable feature of organizational life, can be managed and mitigated. However, a key challenge in redefining groups is that the easiest place to draw boundaries from a social identity perspective may not be the best place from one of system design. Narrowly defined groups forge strong identities more easily, but broader groups facilitate coordination of care by minimizing the number of boundaries patients must traverse. PRACTICE IMPLICATIONS: A thoughtfully designed combination of strategies may help to improve intergroup relations and their impact on flow. It may be ideal to foster a "mosaic" identity that affirms group allegiances at multiple levels.

Can facility-based transitional care improve patient flow? Lessons from four Canadian regions.

Units providing transitional, subacute, or restorative care represent a common intervention to facilitate patient flow and improve outcomes for lower acuity (often older) inpatients; however, little is known about Canadian health systems' experiences with such "transition units." This comparative case study of diverse units in four health regions (48 interviews) identified important success factors and pitfalls. A fundamental requirement for success is to clearly define the unit's intended population and design the model around its needs. Planners must also ensure that the unit be resourced and staffed to deliver truly restorative care. Finally, streamlined processes must be developed to help patients access and move through the unit. Units that were perceived as more effective appeared to have satisfactorily addressed these population, capacity, and process issues, whereas those perceived as less effective continued to struggle with them. Findings suggest principles to support optimal design and implementation of transition units.

The stipulation-stimulation spiral: A model of system change.

This paper proposes a general model, based on what is known about the nature of (complex) systems, of how systems-in particular, health care systems-respond to attempted change. Inferences are drawn from a critical literature review and reinterpretation of two primary studies. The two fundamental system-change approaches are "stipulation" and "stimulation": stip(ulation) attempts to elicit a specific response from the system; stim(ulation) encourages the system to generate diverse responses. Each has a unique strength: stip's is precision, the ability to directly impact the desired outcome and only that outcome; stim's is resonance, the ability to take advantage of behavior already present within the system. Each approach's inherent strength is its complement's inherent weakness; thus, stip and stim often clash if attempted simultaneously but can reinforce each other if applied in alternation. Opposite patterns (the "stip-stim spiral" vs "stip-stim stalemate") are observed to underpin successful vs failed system change: The crucial difference is whether decision-makers respond to a need for precision/resonance by strengthening the appropriate approach (stipulation/stimulation, respectively), or merely by weakening its complement. With further validation, the model has the potential to yield a more fundamental understanding of why system-change efforts fail and how they can succeed.

Primary care renewal strategies in Manitoba: Family physicians' perceptions.

OBJECTIVE: To understand family physicians' perceptions of Manitoba's strategies for primary care renewal or reform (PCR). DESIGN: Qualitative substudy of an explanatory case study. SETTING: Rural and urban Manitoba. PARTICIPANTS: A total of 60 family physicians (31 fee-for-service physicians, 26 alternate-funded physicians, and 3 physicians representing provincial physician organizations). METHODS: Semistructured interviews and focus groups. MAIN FINDINGS: Many physicians were hesitant to participate in PCR initiatives, perceiving clear risks but uncertain benefits to patients and providers. Additional barriers to participation included concerns about the adequacy and import of communication about PCR, the meaningfulness of opportunities for physician "voice," and the trustworthiness of decision makers. There was an appetite for tailored, clinic-level support in addressing concrete, physician-identified problems; however, the initiatives on offer were not widely viewed as providing such support. CONCLUSION: Although some of the observed barriers might fade over time, concentrating PCR efforts on the everyday realities of family physician practice might be the best way to build a primary care system that works for patients and providers.

Advancing the evaluation of integrated knowledge translation.

BACKGROUND: Integrated knowledge translation (IKT) flows from the premise that knowledge co-produced with decision-makers is more likely to inform subsequent decisions. However, evaluations of manager/policy-maker-focused IKT often concentrate on intermediate outcomes, stopping short of assessing whether research findings have contributed to identifiable organisational action. Such hesitancy may reflect the difficulty of tracing the causes of this distal, multifactorial outcome. This paper elucidates how an approach based on realistic evaluation could advance the field. MAIN TEXT: Realistic evaluation views outcomes as a joint product of intervention mechanisms and context. Through identification of context-mechanism-outcome configurations, it enables the systematic testing and refinement of 'mid-range theory' applicable to diverse interventions that share a similar underlying logic of action. The 'context-sensitive causal chain' diagram, a tool adapted from the broader theory-based evaluation literature, offers a useful means of visualising the posited chain from activities to outcomes via mechanisms, and the context factors that facilitate or disrupt each linkage (e.g. activity-mechanism, mechanism-outcome). Drawing on relevant literature, this paper proposes a context-sensitive causal chain by which IKT may generate instrumental use of research findings (i.e. direct use to make a concrete decision) and identifies an existing tool to assess this outcome, then adapts the chain to describe a more subtle, indirect pathway of influence. Key mechanisms include capacity- and relationship-building among researchers and decision-makers, changes in the (perceived) credibility and usability of findings, changes in decision-makers' beliefs and attitudes, and incorporation of new knowledge in an actual decision. Project-specific context factors may impinge upon each linkage; equally important is the organisation's absorptive capacity, namely its overall ability to acquire, assimilate and apply knowledge. Given a sufficiently poor decision-making environment, even well-implemented IKT that triggers important mechanisms may fall short of its desired outcomes. Further research may identify additional mechanisms and context factors. CONCLUSION: By investigating 'what it is about an intervention that works, for whom, under what conditions', realistic evaluation addresses questions of causality head-on without sacrificing complexity. A realist approach could contribute greatly to our ability to assess - and, ultimately, to increase - the value of IKT.

Planning without action and action without planning? Examining a regional health system's efforts to improve patient flow, 1998-2013.

Most health care organizations engage in formal and informal planning, yet their improvement initiatives may remain disjointed and reactive. Research on organizational decision-making has found that the "discovery" approach (seek and assess multiple options before selecting one) outperforms "idea imposition" (identify 1 option, then gather information to [dis]confirm it), yet is observed relatively infrequently. Might this imply that discovery frequently collapses before fruition? This qualitative study sought to better understand the planning-action disjunction, as observed in 1 organization, by comparing its planning processes against the discovery approach. It focused on a Canadian regional health system's recurrent, unsuccessful attempts to improve patient flow. Through extensive document review supplemented by interviews with 62 managers, it identified all relevant regional plans/reports produced during a 15-year period and followed each recommendation forward in time to discover its fate. Each report presented a lengthy, unprioritized list of disparate recommendations, few of which progressed to full implementation. It appeared that decision-makers repeatedly embarked on a discovery approach, but rapidly allowed it to splinter into multiple idea-imposition approaches; numerous options were generated, but never evaluated against each other. Thus, the product of each planning process was not a coherent strategy but a list of disconnected actions.

The three paradoxes of patient flow: an explanatory case study.

BACKGROUND: Health systems in many jurisdictions struggle to reduce Emergency Department congestion and improve patient flow across the continuum of care. Flow is often described as a systemic issue requiring a "system approach"; however, the implications of this idea remain poorly understood. Focusing on a Canadian regional health system whose flow problems have been particularly intractable, this study sought to determine what system-level flaws impede healthcare organizations from improving flow. METHODS: This study drew primarily on qualitative data from in-depth interviews with 62 senior, middle and departmental managers representing the Region, its programs and sites; quantitative analysis of key flow indicators (1999-2012) and review of ~700 documents furnished important context. Examination of the interview data revealed that the most striking feature of the dataset was contradiction; accordingly, a technique of dialectical analysis was developed to examine observed contradictions at successively deeper levels. RESULTS: Analysis uncovered three paradoxes: "Many Small Successes and One Big Failure" (initiatives improve parts of the system but fail to fix underlying system constraints); "Your Innovation Is My Aggravation" (local innovation clashes with regional integration); and most critically, "Your Order Is My Chaos" (rules that improve service organization for my patients create obstacles for yours). This last emerges when some entities (sites/hospitals) define their patients in terms of their location in the system, while others (regional programs) define them in terms of their needs/characteristics. As accountability for improving flow was distributed among groups that thus variously defined their patients, local efforts achieved little for the overall system, and often clashed with each other. These paradoxes are indicative of a fundamental antagonism between the system's parts and the whole. CONCLUSION: An accretion of flow initiatives in all parts of the system will never add up to a system approach, and may indeed perpetuate the paradoxes. What is needed is a coherent strategy of defining patient populations by needs, analyzing their entire trajectories of care, and developing consistent processes to better meet those needs.

A comparative analysis of centralized waiting lists for patients without a primary care provider implemented in six Canadian provinces: study protocol.

BACKGROUND: Having a regular primary care provider (i.e., family physician or nurse practitioner) is widely considered to be a prerequisite for obtaining healthcare that is timely, accessible, continuous, comprehensive, and well-coordinated with other parts of the healthcare system. Yet, 4.6 million Canadians, approximately 15% of Canada's population, are unattached; that is, they do not have a regular primary care provider. To address the critical need for attachment, especially for more vulnerable patients, six Canadian provinces have implemented centralized waiting lists for unattached patients. These waiting lists centralize unattached patients' requests for a primary care provider in a given territory and match patients with providers. From the little information we have on each province's centralized waiting list, we know the way they work varies significantly from province to province. The main objective of this study is to compare the different models of centralized waiting lists for unattached patients implemented in six provinces of Canada to each other and to available scientific knowledge to make recommendations on ways to improve their design in an effort to increase attachment of patients to a primary care provider. METHODS: A logic analysis approach developed in three steps will be used. Step 1: build logic models that describe each province's centralized waiting list through interviews with key stakeholders in each province; step 2: develop a conceptual framework, separate from the provincially informed logic models, that identifies key characteristics of centralized waiting lists for unattached patients and factors influencing their implementation through a literature review and interviews with experts; step 3: compare the logic models to the conceptual framework to make recommendations to improve centralized waiting lists in different provinces during a pan Canadian face-to-face exchange with decision-makers, clinicians and researchers. DISCUSSION: This study is based on an inter-provincial learning exchange approach where we propose to compare centralized waiting lists and analyze variations in strategies used to increase attachment to a regular primary care provider. Fostering inter-provincial healthcare systems connectivity to improve centralized waiting lists' practices across Canada can lever attachment to a regular provider for timely access to continuous, comprehensive and coordinated healthcare for all Canadians and particular for those who are vulnerable.

Regional consolidation of orthopedic surgery: impacts on hip fracture surgery access and outcomes.

BACKGROUND: Timely access to orthopedic trauma surgery is essential for optimal outcomes. Regionalization of some types of surgery has shown positive effects on access, timeliness and outcomes. We investigated how the consolidation of orthopedic surgery in 1 Canadian health region affected patients requiring hip fracture surgery. METHODS: We retrieved administrative data on all regional emergency department visits for lower-extremity injury and all linked inpatient stays from January 2010 through March 2013, identifying 1885 hip-fracture surgeries. Statistical process control and interrupted time series analysis controlling for demographics and comorbidities were used to assess impacts on access (receipt of surgery within 48-h benchmark) and surgical outcomes (complications, in-hospital/30-d mortality, length of stay). RESULTS: There was a significant increase in the proportion of patients receiving surgery within the benchmark. Complication rates did not change, but there appeared to be some decrease in mortality (significant at 6 mo). Length of stay increased at a hospital that experienced a major increase in patient volume, perhaps reflecting challenges associated with patient flow. CONCLUSION: Regionalization appeared to improve the timeliness of surgery and may have reduced mortality. The specific features of the present consolidation (including pre-existing interhospital performance variation and the introduction of daytime slates at the referral hospital) should be considered when interpreting the findings.

CONTEXTE: En traumatologie, l'accès rapide à la chirurgie orthopédique est essentiel pour l'obtention de résultats optimaux. La régionalisation de certains types de chirurgie a eu des effets positifs sur l'accès aux soins, leur rapidité et leurs résultats. Nous avons vérifié l'effet qu'a eu la consolidation des soins chirurgicaux orthopédiques dans une région sanitaire canadienne sur les patients qui ont eu recours à la chirurgie pour une fracture de la hanche. MÉTHODES: Nous avons obtenu les données administratives concernant toutes les consultations dans les services d'urgence régionaux pour des blessures aux membres inférieurs et nous les avons corrélées avec les séjours hospitaliers de janvier 2010 à mars 2013. Nous avons ainsi recensé 1885 chirurgies pour fracture de la hanche. Nous avons utilisé la maîtrise statistique des procédés et le modèle chronologique interrompu et nous avons tenu compte des caractéristiques démographiques et des comorbidités pour évaluer les impacts sur l'accès aux interventions (attente limite de 48 h pour obtenir la chirurgie) et leurs résultats (complications, mortalité perhospitalière à 30 j et durée des séjours). RÉSULTATS: On a noté une augmentation significative de la proportion de patients traités par chirurgie à l'intérieur des délais. Les taux de complications n'ont pas varié, mais il semble y avoir eu une certaine diminution de la mortalité (significative à 6 mois). La durée des séjours a augmenté dans un hôpital qui a connu un accroissement majeur de sa clientèle, témoignant peut-être de difficultés liées à l'afflux de patients. CONCLUSION: La régionalisation a semblé améliorer l'accès rapide à la chirurgie et pourrait avoir réduit la mortalité. Il faut tenir compte des caractéristiques spécifiques de la présente consolidation (y compris la variation préexistante du rendement interhospitalier et la création de listes de jour à l'hôpital de référence) avant d'interpréter ces conclusions.

What if implementation is not the problem? Exploring the missing links between knowledge and action.

Given all the available knowledge about effective implementation, why do many organizations continue to have-or appear to have-an implementation problem? Analysis of a 7-year corpus of reports by a Canadian health region's "embedded" research and evaluation unit sought to discover the source of the region's intractable difficulty implementing improvement. Findings suggested that the problem was neither a lack of knowledge (decision-makers displayed sophisticated understanding of fundamental issues) nor an inability to take action (there existed sufficient capacity to implement change). However, managers' high-level knowledge was not made actionable, and micro-level decision-making often produced piecemeal actions inadequately informed by existing knowledge. The problem arose at the stage of "operationalization"-the identification of concrete, executable actions fully informed by knowledge of complex, system-level issues. Yet this crucial phase is a focus of neither the implementation nor knowledge translation (KT) literatures. The organizational decision-making literature reveals how decision-makers initiate operationalization (i.e., by setting the direction for a discovery approach) but not how they can ensure its successful completion. The focus of KT research and practice should expand to explicating and improving decision-making, lest KT become an exercise of infusing content into a broken process. Copyright © 2014 John Wiley & Sons, Ltd.

Patient characteristics associated with longer emergency department stay: a rapid review.

BACKGROUND: Prolonged emergency department (ED) stays make a disproportionate contribution to ED overcrowding, but the factors associated with longer stays have not been systematically reviewed. OBJECTIVE: To identify the patient characteristics associated with ED length of stay (LOS) and ascertain whether a predictive model existed. METHODS: This rapid systematic review included published, English-language studies that assessed at least one patient-level predictor of ED LOS (defined as a continuous or dichotomous variable) in an adult or mixed adult/paediatric population within an Organization for Economic Cooperation and Development country. Findings were synthesised narratively. RESULTS: We identified 35 relevant studies; most included multiple predictors, but none developed a predictive model. The factors most commonly associated with long ED LOS were need for admission (10 of 10 studies) and older age (which may be a proxy for age-related differences in health condition and severity; 9 of 10), receipt of diagnostic tests or consults (8 of 8) and ambulance arrival (4 of 5). Acuity often showed a bell-shaped relationship with LOS (ie, patients with moderate acuity stayed longest). LIMITATIONS: Methodological choices made in the interests of rapidity limited the review's comprehensiveness and depth. CONCLUSIONS: Despite a sizeable body of literature, the available information is insufficiently precise to inform clinical or service-planning decisions; there is a need for a predictive model, including specific patient complaints. Deeper understanding of the determinants of ED LOS could help to identify patients and/or populations who require special intervention or resources to prevent a protracted stay.

Assessing the organizational impact of patient involvement: a first STEPP.

Purpose - Patient involvement in the design and improvement of health services is increasingly recognized as an essential part of patient-centred care. Yet little research, and no measurement tool, has addressed the organizational impacts of such involvement. The paper aims to discuss these issues. Design/methodology/approach - The authors developed and piloted the scoresheet for tangible effects of patient participation (STEPP) to measure the instrumental use of patient input. Its items assess the magnitude of each recommendation or issue brought forward by patients, the extent of the organization's response, and the apparent degree of patient influence on this response. In collaboration with teams (staff) from five involvement initiatives, the authors collected interview and documentary data and scored the STEPP, first independently then jointly. Feedback meetings and a "challenges log" supported ongoing improvement. Findings - Although researchers' and teams' initial scores often diverged, the authors quickly reached consensus as new information was shared. Composite scores appeared to credibly reflect the degree of organizational impact, and were associated with salient features of the involvement initiatives. Teams described the STEPP as easy to use and useful for monitoring and accountability purposes. The tool seemed most suitable for initiatives in which patients generated novel, concrete recommendations; less so for broad public consultations of which instrumental use was not a primary goal. Originality/value - The STEPP is a promising, first-in-class tool with potential usefulness to both researchers and practitioners. With further research to better establish its reliability and validity, it could make a valuable contribution to full mixed-methods evaluation of patient involvement.

The politics of patient-centred care.

BACKGROUND: Despite widespread belief in the importance of patient-centred care, it remains difficult to create a system in which all groups work together for the good of the patient. Part of the problem may be that the issue of patient-centred care itself can be used to prosecute intergroup conflict. OBJECTIVE: This qualitative study of texts examined the presence and nature of intergroup language within the discourse on patient-centred care. METHODS: A systematic SCOPUS and Google search identified 85 peer-reviewed and grey literature reports that engaged with the concept of patient-centred care. Discourse analysis, informed by the social identity approach, examined how writers defined and portrayed various groups. RESULTS: Managers, physicians and nurses all used the discourse of patient-centred care to imply that their own group was patient centred while other group(s) were not. Patient organizations tended to downplay or even deny the role of managers and providers in promoting patient centredness, and some used the concept to advocate for controversial health policies. Intergroup themes were even more obvious in the rhetoric of political groups across the ideological spectrum. In contrast to accounts that juxtaposed in-groups and out-groups, those from reportedly patient-centred organizations defined a 'mosaic' in-group that encompassed managers, providers and patients. CONCLUSION: The seemingly benign concept of patient-centred care can easily become a weapon on an intergroup battlefield. Understanding this dimension may help organizations resolve the intergroup tensions that prevent collective achievement of a patient-centred system.

Effectiveness of internet-based interventions for children, youth, and young adults with anxiety and/or depression: a systematic review and meta-analysis.

BACKGROUND: The majority of internet-based anxiety and depression intervention studies have targeted adults. An increasing number of studies of children, youth, and young adults have been conducted, but the evidence on effectiveness has not been synthesized. The objective of this research is to systematically review the most recent findings in this area and calculate overall (pooled) effect estimates of internet-based anxiety and/or depression interventions. METHODS: We searched five literature databases (PubMed, EMBASE, CINAHL, PsychInfo, and Google Scholar) for studies published between January 1990 and December 2012. We included studies evaluating the effectiveness of internet-based interventions for children, youth, and young adults (age <25 years) with anxiety and/or depression and their parents. Two reviewers independently assessed the risk of bias regarding selection bias, allocation bias, confounding bias, blinding, data collection, and withdrawals/dropouts. We included studies rated as high or moderate quality according to the risk of bias assessment. We conducted meta-analyses using the random effects model. We calculated standardized mean difference and its 95% confidence interval (95% CI) for anxiety and depression symptom severity scores by comparing internet-based intervention vs. waitlist control and internet-based intervention vs. face-to-face intervention. We also calculated pooled remission rate ratio and 95% CI. RESULTS: We included seven studies involving 569 participants aged between 7 and 25 years. Meta-analysis suggested that, compared to waitlist control, internet-based interventions were able to reduce anxiety symptom severity (standardized mean difference and 95% CI = -0.52 [-0.90, -0.14]) and increase remission rate (pooled remission rate ratio and 95% CI =3.63 [1.59, 8.27]). The effect in reducing depression symptom severity was not statistically significant (standardized mean difference and 95% CI = -0.16 [-0.44, 0.12]). We found no statistical difference in anxiety or depression symptoms between internet-based intervention and face-to-face intervention (or usual care). CONCLUSIONS: The present analysis indicated that internet-based interventions were effective in reducing anxiety symptoms and increasing remission rate, but not effective in reducing depression symptom severity. Due to the small number of higher quality studies, more attention to this area of research is encouraged. TRIAL REGISTRATION: PROSPERO registration: CRD42012002100.

The rules of engagement: physician engagement strategies in intergroup contexts.

PURPOSE: Recognition of the importance and difficulty of engaging physicians in organisational change has sparked an explosion of literature. The social identity approach, by considering engagement in terms of underlying group identifications and intergroup dynamics, may provide a framework for choosing among the plethora of proposed engagement techniques. This paper seeks to address this issue. DESIGN/METHODOLOGY/APPROACH: The authors examined how four disparate organisations engaged physicians in change. Qualitative methods included interviews (109 managers and physicians), observation, and document review. FINDINGS: Beyond a universal focus on relationship-building, sites differed radically in their preferred strategies. Each emphasised or downplayed professional and/or organisational identity as befit the existing level of inter-group closeness between physicians and managers: an independent practice association sought to enhance members' identity as independent physicians; a hospital, engaging community physicians suspicious of integration, stressed collaboration among separate, equal partners; a developing integrated-delivery system promoted alignment among diverse groups by balancing "systemness" with subgroup uniqueness; a medical group established a strong common identity among employed physicians, but practised pragmatic co-operation with its affiliates. RESEARCH LIMITATIONS/IMPLICATIONS: The authors cannot confirm the accuracy of managers perceptions of the inter-group context or the efficacy of particular strategies. Nonetheless, the findings suggested the fruitfulness of social identity thinking in approaching physician engagement. PRACTICAL IMPLICATIONS: Attention to inter-group dynamics may help organisations engage physicians more effectively. ORIGINALITY/VALUE: This study illuminates and explains variation in the way different organisations engage physicians, and offers a theoretical basis for selecting engagement strategies.

Impact of a regional acute care surgery model on patient access and outcomes.

BACKGROUND: The consolidation of acute care surgery (ACS) services at 3 of 6 hospitals in a Canadian health region sought to alleviate a relative shortage of surgeons able to take emergency call. We examined how this affected patient access and outcomes. METHODS: Using the generalized linear model and statistical process control, we analyzed ACS-related episodes that occurred between 39 months prior to and 17 months after the model's implementation (n = 14,713). RESULTS: Time to surgery increased after the consolidation. Wait times increased primarily for patients presenting at nonreferral hospitals who were likely to require transfer to a referral hospital. Although ACS teams enabled referral hospitals to handle a much higher volume of patients without increasing within-hospital wait times, overall system wait times were lengthened by the growing frequency of patient transfers. Wait times for inpatient admission were difficult to interpret because there was a trend toward admitting patients directly to the ACS service, bypassing the emergency department (ED). For patients who did go through the ED, wait times for inpatient admission increased after the consolidation; however, this trend was cancelled out by the apparently zero waits of patients who bypassed the ED. Regionalization showed no impact on length of stay, readmissions, mortality or complications. CONCLUSION: Consolidation enabled the region to ensure adequate surgical coverage without harming patients. The need to transfer patients who presented at nonreferral hospitals led to longer waits.

CONTEXTE: Le regroupement des services chirurgicaux d'urgence (SCU) dans 3 hôpitaux sur 6 d'une région sanitaire canadienne visait à contrer une relative pénurie de chirurgiens capables d'effectuer les interventions d'urgence. Nous en avons analysé l'impact sur l'accessibilité des services et sur les résultats chez les patients. MÉTHODES: À l'aide du modèle linéaire généralisé et d'un contrôle statistique des procédés, nous avons analysé les cas adressés aux SCU entre 39 mois précédant et 17 mois suivant l'entrée en vigueur du regroupement des services (n = 14 713). RÉSULTANTS: L'intervalle avant l'intervention chirurgicale s'est allongé après le regroupement des services. Les temps d'attente ont principalement augmenté pour les patients qui consultaient dans un hôpital de premier recours d'où ils étaient susceptibles d'être réorientés vers un hôpital de référence. Même si les équipes des SCU ont permis aux hôpitaux de référence de gérer un volume beaucoup plus important de patients sans augmentation du temps d'attente à l'hôpital même, le temps d'attente dans son ensemble s'est prolongé à l'échelle du système en raison de l'accroissement du nombre de transferts. Les temps d'attente pour les hospitalisations ont été difficiles à interpréter parce qu'on avait tendance à admettre les patients directement aux SCU, en contournant les services d'urgences. Pour les patients qui passaient par les urgences, les temps d'attente pour une hospitalisation ont augmenté après le regroupement; toutefois, cette tendance a été compensée par l'attente pour ainsi dire nulle des patients qui contournaient les services d'urgence. La régionalisation n'a exercé aucun impact sur la durée du séjour, les réadmissions, la mortalité ou les complications. CONCLUSIONS: Le regroupement a permis à la région d'assurer une couverture chirurgicale adéquate sans nuire aux patients. La nécessité de réorienter des patients vers les hôpitaux de référence a contribué à prolonger les temps d'attente.

Protocol for developing a set of performance measures to monitor and evaluate delirium care quality for older adults in the emergency department using a modified e-Delphi process.

INTRODUCTION: Older adults are at high risk of developing delirium in the emergency department (ED). Delirium associated with an ED visit is independently linked to poorer outcomes such as increased length of hospital stay and mortality. Performance measures (PMs) are needed to identify variations in the quality of delirium care to help focus improvement efforts where they are most needed. A preliminary list of 11 quality statements and 24 PMs was developed based on a synthesis of high-quality clinical practice guidelines. The purpose of this study is to gain consensus on a subset of PMs that can be used to evaluate delirium care quality for older ED patients. METHODS AND ANALYSIS: This protocol for a modified e-Delphi study is informed by the Guidance on Conducting and REporting DElphi Studies. Clinical experts from across Canada and internationally will be recruited through peer referral, professional organisations and social media calls for expressions of interest. A minimum of 17 participants will be recruited. The primary survey for each round will consist of closed-ended questions with the opportunity to provide comments to justify decisions and clarify understanding. Using 9-point Likert scales, participants will rate each quality statement according to the concepts of importance and actionability, then its associated PMs according to the concept of necessity. Results will be fed back to participants in subsequent rounds. A priori stopping criteria have been defined in terms of consensus and stability. A minimum of three rounds will be undertaken to allow participants to have feedback, revise previous responses, then stabilise responses. ETHICS AND DISSEMINATION: Ethical approval was provided at the University of Manitoba Health Research Ethics Board (ID HS25728 (H2022:340)). Informed consent will be obtained electronically using the Research Electronic Data Capture secure online platform. Knowledge translation and dissemination will be done through traditional (eg, conference presentations, peer-reviewed publications) and non-traditional (eg, ED Grand Rounds) strategies.